| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,166 |
2,166 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
2,917 |
2,914 |
$71K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
482 |
311 |
$57K |
| D1110 |
Prophylaxis - adult |
1,029 |
1,027 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,655 |
1,655 |
$34K |
| D1206 |
Topical application of fluoride varnish |
655 |
655 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,059 |
1,053 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
852 |
849 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
53 |
$6K |
| D0272 |
Bitewings - two radiographic images |
246 |
246 |
$5K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$4K |
| D0274 |
Bitewings - four radiographic images |
90 |
90 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$2K |